Audio Bible Order Qualification Form


Date: _________________

Applicant's Name:___________________________________________________ 
First Middle Last

Preferred title/name for mailing: ___________________________________________

Address: _______________________________________________________
Street 
_______________________________________________________
City, State and zip 
Phone: _____________________________ 

E-mail: _________________________________

Nature of Impairment: __________________________________________________
Please see eligibility requirements.

Free Materials Requested: ____________________________________________

The following certification must be completed by a competent authority as 
recognized by the National Library Service for the Blind and Physically 
Handicapped; such as professional staff or agency or organization for the 
blind, a librarian, rehab worker, rehab teacher, doctor, etc.

Certifying Authority: ___________________________________ 

Title: __________________

Organization/Agency:_______________________________________

Organization Address: _______________________________________________________
Street

_______________________________________________________
City, State and zip 

Phone: _______________________________ 

Date: ________________________________

Certifying Authority's Signature:

________________________________________________


Please return this form to:
Audio Bibles for the Blind
a division of Aurora Ministries
P.O. Box 621
Bradenton, FL 34206 USA 
tel.941-748-3031 Fax.941-748-2625